Has UNAIDS left the Middle East and north Africa behind?
Authors: Nesrine A Rizk, Remie El Helou, Sawsan AlMukdad, Sasha Fahme, Ghina R Mumtaz, Hiam Chemaitelly, Houssein H Ayoub, Aisha Osman, Hakima Himmich, Mehdi Karkouri, Abdullatif Al Khal, Mohamed Hassany, Laith J Abu-Raddad
Journal: The Lancet HIV (2023)

The HIV epidemic is growing across nearly all countries in the Middle East and north Africa.1Mumtaz GR Chemaitelly H AlMukdad S et al.Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.Lancet HIV. 2022; 9: e506-e516Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar The region has seen a 61% increase in new HIV infections from 2010 to 2022, the highest regional rate of increase in the world.2UANIDSThe path that ends AIDS: UNAIDS global AIDS update 2023. Geneva.https://unaids.org/en/resources/documents/2023/global-aids-update-2023Date: July 13, 2023Date accessed: July 13, 2023Google Scholar The epidemic is disproportionately affecting vulnerable and stigmatised populations, namely people who inject drugs, men who have sex with men, transgender people, and female sex workers.1Mumtaz GR Chemaitelly H AlMukdad S et al.Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.Lancet HIV. 2022; 9: e506-e516Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar HIV prevalence has been increasing for two decades in these key populations in the Middle East and north Africa.1Mumtaz GR Chemaitelly H AlMukdad S et al.Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.Lancet HIV. 2022; 9: e506-e516Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar The Middle East and north Africa lags behind other regions on key indicators for HIV response, including access to prevention services, testing, and antiretroviral therapy and linkage to care.1Mumtaz GR Chemaitelly H AlMukdad S et al.Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.Lancet HIV. 2022; 9: e506-e516Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 3Mugisa B Sabry A Hutin Y Hermez J HIV epidemiology in the WHO Eastern Mediterranean region: a multicountry programme review.Lancet HIV. 2022; 9: e112-e119Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar The region has been at the centre of sociopolitical and economic crises, characterised by protracted armed conflicts and massive forced displacement.1Mumtaz GR Chemaitelly H AlMukdad S et al.Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.Lancet HIV. 2022; 9: e506-e516Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar HIV has rarely been a priority for policy makers because of sociocultural sensitivities,4Abu-Raddad L Akala FA Semini I Riedner G Wilson D Tawil O Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: time for strategic action. The World Bank Press, Washington, DC2010Crossref Google Scholar reflected in extremely low financial investment in HIV response compared with other regions.5UNAIDSIn danger: UNAIDS global AIDS update 2022.https://www.unaids.org/en/resources/documents/2022/in-danger-global-aids-updateDate: July 27, 2022Date accessed: April 21, 2023Google Scholar The region also has among the highest proportion of countries criminalising key populations and imposing restrictions on entry, residence, or stay of people living with HIV from other countries, thereby fuelling widespread stigma and discrimination. International involvement and increased investment are needed in the Middle East and north Africa to address this epidemic. The poor performance on key indicators for HIV response in the Middle East and north Africa should trigger a call to action and an appeal to strengthen HIV response and adopt realistic, serious, and committed strategic plans at the regional level. The opposite is happening. As a group of civil society activists, health-care providers, and academic researchers working on HIV in the Middle East and north Africa, we were dismayed to learn that UNAIDS closed its regional support team office for the Middle East and north Africa in June, 2023. The announcement regarding the Middle East and north Africa office follows the closure of the UNAIDS country office in Djibouti in 2022, the only country in the region with a generalised HIV epidemic.4Abu-Raddad L Akala FA Semini I Riedner G Wilson D Tawil O Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: time for strategic action. The World Bank Press, Washington, DC2010Crossref Google Scholar Furthermore, the five remaining country offices that were previously under the jurisdiction of the regional support team for the Middle East and north Africa have also been split up, with those in Algeria, Morocco, and Tunisia being handled by the regional office in western and central Africa (based in Dakar, Senegal) and those in Egypt and Sudan reporting to the regional office in eastern and southern Africa (based in Johannesburg, South Africa). It is unclear how the remaining 14 countries previously covered by the regional office will be served now that this office is closed. UNAIDS is the primary organisation with the UN-endorsed mandate to gather and connect diverse partners across countries to stop the spread of HIV. The UNAIDS mission is reflected in its regional adaptation of the Global AIDS Strategy 2021–2026, which focuses on the particular needs of the Middle East and north Africa, including enhanced cross-country collaboration to improve epidemiological understanding and collection of strategic information, increased attention to HIV in humanitarian crises, and improved laws and policies to promote gender equality and human rights.6UNAIDSEnd inequalities. End AIDS. Global AIDS strategy 2021–2026.https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026Date: March 25, 2021Date accessed: April 21, 2023Google Scholar The emphasis in the Global AIDS Strategy 2021–2026 on supporting community-led responses to HIV has been particularly welcome in the Middle East and north Africa, because community response is essential in the absence of adequate governmental response. Controlling the epidemic in the region has so far relied on actions of local non-governmental organisations (NGOs) and community associations supported by UNAIDS and international donors.1Mumtaz GR Chemaitelly H AlMukdad S et al.Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.Lancet HIV. 2022; 9: e506-e516Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar With the support of UNAIDS, such groups as MENA Rosa, the Middle East and North Africa Harm Reduction Association, the Society for Inclusion and Development in Communities and Care, and other NGOs have emerged as models of successful regional networks fighting the epidemic. These organisations rarely benefit from public funding and often do not have the legal authority to provide effective prevention and treatment interventions to key populations and people living with HIV. These networks were built over many years, and many more years will be needed to develop similar networks, relationships, and collaborations now that the UNAIDS regional support team in the Middle East and north Africa is no longer present to fulfil its leadership role. The reassignment of countries from the regional support team to two far-flung regional offices in Dakar and Johannesburg poses a huge challenge for civil society and other external partners. Among these external partners are other regionally oriented UN agencies and ourselves, who now have to deal with many regional offices (rather than a single regional support team office) in parts of the world with different epidemiological, cultural, and linguistic contexts and priorities to those in the Middle East and north Africa. It is inconceivable to us that UNAIDS is reducing its presence in the Middle East and north Africa. As stakeholders and HIV experts from this region, we feel entitled to ask that UNAIDS reconsider this move, even more so since the decision to close the regional office did not involve prior consultation with key partners, among them civil society and host governments in the region. Although the organisation has justified the closure of the regional office with funding shortfalls, UNAIDS has yet to publicly present a risk–benefit analysis of the closure versus other cost-cutting measures that the organisation has made or could make. Indeed, during the 58th round of the Arab League's Council of Health Ministers held in Algeria in March, 2023, the Council of Health Ministers expressed extreme concern over the proposed closure and break-up of the region and urged UNAIDS to rethink its plan.7Middle East News AgencyArab health ministers approved Egyptian proposal to establish the Arab Agency for Medicine.https://www.mena.org.eg/ar/news/dbcall/table/textnews/id/10066569Date: March 14, 2023Date accessed: April 23, 2023Google Scholar Such reservations were reiterated at the UNAIDS Programme Coordinating Board meeting in Geneva in June, 2023 (ie, the UNAIDS biannual stakeholder gathering), during which a representative of the African NGO delegation noted the anxiety of civil society in the Middle East and north Africa over the effects of the closure of the regional office and questioned whether there had been "sufficient consultations" to ensure continuity of the HIV response.8NGO Delegation to the UNAIDS PCBAgenda item 5—52nd PCB Meeting. Update on strategic human resources management issues. NGO Delegate representing Africa: intervention delivered by Myles John Mwansa.https://unaidspcbngo.org/pcb-meeting/52-unaids-pcb-meeting/Date: June, 2023Date accessed: July 6, 2023Google Scholar At the same meeting, the Libyan Government delegation (which represents the Middle East and north Africa on the UNAIDS Programme Coordinating Board) took the opportunity during its official intervention to "respectfully request that UNAIDS reconsider its decision to close the Regional Support Team for the MENA region…this closure will unquestionably have a major impact on how the countries in north Africa respond. Separating the countries in the North Africa region and having them report to different regional offices, will further complicate communication and collaboration efforts, adding unnecessary challenges to the already demanding situation of HIV".9Abusedra LF. Statement by Lamia Fathi Abusedra, Ambassador, Permanent Representative, State of Libya Permanent Mission to the United Nations Geneva. 52nd UNAIDS PCB Meeting; June 26–28, 2023.Google Scholar The Global AIDS Strategy 2021–2026 clearly states "End Inequalities. End AIDS",6UNAIDSEnd inequalities. End AIDS. Global AIDS strategy 2021–2026.https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026Date: March 25, 2021Date accessed: April 21, 2023Google Scholar building on UNAIDS' longstanding "vision of zero new HIV infections...and a principle of leaving no one behind".10UNAIDSUNAIDS—saving lives, leaving no one behind.https://www.unaids.org/en/resources/documents/2018/unaids_leading_global_effort_to_end_aidsDate: Feb 12, 2018Date accessed: April 10, 2023Google Scholar We ask UNAIDS to reconsider a decision that makes the Middle East and north Africa less equal to other regions when it comes to vital UN engagement on HIV. UNAIDS, please do not leave us behind. We declare no competing interests.